505-662-4234 Los Alamos
505-672-3993 White Rock

Patient Forms

We are also happy to offer you the option to download, print and complete forms to reduce wait times.
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.

New Patient Forms

Patient Information Form
Notice of Privacy Practices and Patient Consent Form
Family History Form

Los Alamos Public Schools Forms

Sports Form
State of New Mexico Concussion Form and Information Sheet
Food Allergy Action Plan Sheet
LAPS School District Forms Link
Return to Athletic Participation
Kindergarten Health Examination by Physician
Permission Form for Administering Medication in Schools 

ADHD Forms

Vanderbilt Parent Forms
Vanderbilt Parent Forms Follow Up
Vanderbilt Teacher Forms
Vanderbilt Teach Forms Follow Up

Asthma Forms

Asthma Action Plan
Asthma Control Test (12 and over)
Asthma Control Test (4 to 11)

Immunization Forms

Permission to Administer Vaccine: English
Permiso Para Administrar La Vacuna
AAP Vaccine Refusal Form

DTap Vaccine
Flu Vaccine - Inactivated
Flu Vaccine - Intranasal
Hep A Vaccination
Hep B Vaccination
HIB Vaccine
HPV

Meningococcal Vaccine 
MMR Vaccine
Tdap Vaccine
Varicella (Chicken Pox) Vaccine

Meningococcal B Vaccine
Pneumococcal 13 Vaccine
Pneumococcal 23 Vaccine
Polio Vaccine
Rotavirus Vaccine
Mulit-vaccine Information Sheet-1 month PE
Typhoid Vaccine

Other Forms

    Adolescent Depression Form 

Ages and Stages Questionnaires (English)


    5-7 mo.ASQ3-Questions
    7-9 mo.ASQ3-Questions
    9-11 mo.ASQ3-Questions
    11-13 mo.ASQ3-Questions
    13-15 mo.ASQ3-Questions
    15-17 mo.ASQ3-Questions
    17-19 mo.ASQ3-Questions
    19-21 mo.ASQ3-Questions
    21-23 mo.ASQ3-Questions
    23-25 mo.ASQ3-Questions

Ages and Stages Questionnaires (Español)

    
    5-7 mo. ASQ3-Preguntas
    9-11 mo.ASQ3-Preguntas
    11-13 mo. ASQ3-Preguntas
    15-17 mo.ASQ3-Preguntas
    17-19 mo.ASQ3-Preguntas

Ages and Stages Activities Forms

    
    1-4 mo. Activities for Infants
    4-8 mo. Activities for Infants
    8-12 mo. Activities for Infants
    12-16 mo. Activities for Infants
    16-20 mo. Activities for Toddlers
    20-24 mo. Activities for Toddlers
    24-30 mo. Activities for Children
    30-36 mo. Activities for Children
    36-48 mo. Activities for Children
    48-60 mo Activities for Children
    60-66 mo. Activities for Children

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